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Medical considerations when treating psychological injuries

Dr Quentin Mungomery, Psychiatrist and Medical Assessment Tribunal Member is providing general practitioners with tips on completing the Work capacity certificate – workers' compensation when a patient presents with a work related psychological injury. This webcast provides suggestions as to what meaningful information to include in the key medical assessment sections within the Work capacity certificate. Understand how this information is utilised by insurers and the patient's employer to assist them to recover at work as part of their rehabilitation.

Download a copy of this film (ZIP/MP4, 88MB)

Welcome to today's webcast for Queensland GPs, proudly  brought to you by the Office of Industrial Relations. The focus of today's  webcast is to support and provide you with practical assistance on preparing a  treatment plan to include capacity for work and functional ability when  managing a patient with a work-related psychological injury.

The Office of Industrial Relations is committed to  delivering short and sharp education to better support Queensland doctors  working within the workers' compensation scheme.

The Office of Industrial Relations prepares and correlates  all the workers' compensation scheme data for Queensland from each of the 29  insurers. The data shows that an average psychological and psychiatric claim  can cost approximately $50,000 and this is continuing to slightly increase with  more time-lost claims finalised. This is much higher than any other injury type  claim. For example, a fracture claim or a strain and sprain for a back are  between $10,000 and $30,000.

The average duration of these claims in 2015-16, were 156.8  days. This is the amount of days that they were off due to their work-related  psychological injury. The OIR are committed to reducing the time off for  psychological injury claims. To support this, the OIR welcomes Dr. Quentin  Mungomery, psychiatrist and member of the Medical Assessment Tribunal. To share  with you some tips on both the treatment plan, relating to capacity for work,  and the functional ability for your patients who present with a work-related  psychological injury. Thank you, Dr. Mungomery.

Hello, this is Quentin Mungomery and thank you for taking  time to listen to this webinar.

In this webinar, we will be providing additional advice and  suggestions to assist with completion of the new work capacity certificate, which  was introduced in July of 2016. This is the second of two webinars on this  topic with our previous presentation focusing on the diagnosis and mechanism of  work-related psychological injuries.

Today we will be focusing on how to complete the remaining  sections of the work capacity certificate, including treatment plan, capacity  for work, functional ability, and return to work rehabilitation planning.  Reduced capacity to work due to psychiatric illness is not always  understandable or clearly observable to others.

Workers' rehabilitation can benefit significantly from an  increased knowledge and understanding of the impact of psychiatric illnesses on  their capacity to rehabilitate and return to work. Having a clear understanding  of the potential impact of such injuries on their capacity to work also assists  with the timely provision of an individualised treatment and return to work  plan and increases the likelihood of a positive outcome.

The nature of work-related psychological injuries often  requires consideration of an integrated treatment approach, such as the bio,  psycho, social model. This model take a broad view that allows attribution of  psychiatric illness outcomes to the intricate and variable interaction of a  range of factors, including biological factors, such as genetics, comorbid  medical conditions, and impact of drugs and alcohol, psychological factors,  including premier personality factors and any associated behavioural issues,  and various cultural, familial, and social factors.

Consideration of these issues assists with the formulation  of an individualised treatment plan to meet the specific treatment and  rehabilitation needs of the injured worker, and can include appropriate  medication strategies, psychological counselling, and referral for special  psychiatric care, and specific pathological and drug and alcohol testing as  required. Considering whether an injured worker's medication may impair their  capacity to work or travel, can be important as some psychotropic and opioid  medications can cause sedative and cognitive issues, especially those with  antihistamine or anticholinergic effects. Comorbid drug and alcohol issues can  also effect work capacity, with consideration of therapeutic strategies to  encourage reduction or abstinence from these substances increasing the  likelihood of successful engagement and return to work activities. Considering  how long an injured worker may require treatment based upon the severity of  their work-related psychiatric injury, also assists with appropriate treatment  planning.

While some work-related psychiatric injuries go on to become  chronic and may require more extended treatment, it is more common for injured  workers to achieve significant recovery once they have had a period of  appropriate treatment and the precipitating work-related stressor or injury has  resolved or stabilised.

This section of the work capacity certificate asks us to  consider the impact of the psychiatric or psychological condition on the  injured worker's capacity to return to work and functional ability. Common  mental disorders can affect a worker's ability to undertake their work  carefully and sustain focus on mentally demanding tasks, and interact  appropriately with customers and work colleagues. Workers often experience  problems with lack of motivation and getting started in the morning as well.

They can also experience problems with feeling anxious prior  to work, with associated avoidance, and have difficulties handling workload due  to mental fatigue. Impairment and work function often crosses over a number of  areas of work functioning, causing increased problems with general areas and  difficulties with more complex motor skills and work speed and productivity.  Capacity for work can also be impaired by medication and any ongoing illicit  drug or alcohol issues.

Cognitive complaints are common in more severe psychiatric  conditions, especially in major depressive illnesses. The most commonly  reported problems are diminished ability to think or concentrate, which can  lead to indecisiveness. Other core symptoms can include problems with  psycho-motor retardation or agitation and motivation, mental and physical  fatigue, insomnia and mood disturbances, which can also cause cognitive  difficulties.

Major psychiatric illnesses have been shown to cause more  specific deficits identifiable on testing in areas of attention, verbal and  nonverbal learning, short-term and working memory, visual and auditory  processing, problem solving and processing speed, and motor functioning. All of  which can potentially affect the worker's functional capacity and may need to  be considered when undertaking return to work planning.

If cognitive issues  become a significant ongoing issue, consideration of other medical causes is  suggested. The injured worker may also benefit from baseline and serial  cognitive testing using instruments such as the mini-mental state examination  or MoCA. And if more marked deficits are identified, consideration for more  formal psychometric testing by a clinical psychologist.

Anxiety disorders such as post-traumatic stress disorder can  also cause similar cognitive deficits but often also present with additional  challenges when considering returning to work planning. If you'd had problems  with fear avoidance of certain work environments, especially if the index  work-related injury was of a more traumatic nature. This may require the  provision of suitable duties in an area away from the index traumatic event or  the opportunity to undertake host employment in another work environment, in  the initial stages of returning to work.

Graded exposure activities to the feared workplace  environment or situation, with the support of a clinical psychologist, can  greatly assist with overcoming any phobic avoidance of this nature.

Provision of a return to work rehabilitation plan at times  can seem a somewhat daunting prospect, especially when attempting to assist a  worker who has a combination of both psychiatric and physical injuries.

Taking the opportunity to liaise with the worker's treating  psychologist and psychiatrist however, can greatly assist with the formulation  of such plans. Identifying tasks that can contribute to emotional refuelling at  work, that the worker finds pleasurable or gives them a sense of competence and  capacity, can also enhance their success of rehabilitation.

Rehabilitation programmes can generally be tailored to  accommodate the impairment associated with most work-related psychiatric  injuries, once a degree of stability and improvement has been achieved and can  also facilitate their further recovery. In closing then, the provision of  relevant clinical information in the work capacity certificate, is of great  assistance in facilitating the injured worker's engagement in treatment and  rehabilitation activities.

Timely and accurate completion of the work capacity  certificate greatly assists with the coordination of treatment and  rehabilitation of the injured worker, towards the goal of returning to work.  And understanding of the potential impact of work-related psychiatric injuries on  the injured worker's capacity to work will also assist with the provision of an  individualised treatment and return to work plan, and increases the likelihood  of a positive outcome.

With help, practitioner's completion of the work capacity  certificate, playing a pivotal role in achieving these goals. Thank you again  for taking time to listen to this webinar and hope that the information  provided will be of assistance in completing the work capacity certificate for  injured workers.

Thank you Dr. Mungomery. And thank you for listening to this  webcast for Queensland GPs, presented to you by the Office of Industrial  Relations. For more information about workers' compensation services, please  visit our dedicated medical practitioner area on our website.

Please look out for future webcasts from the Office of  Industrial Relations.